ScienMag: Usual antidepressants may not work in patients with chronic illness

[Wonko]

erm..is it just me or does this sound like a recipe for a totally f'd up system. Surely they shouldn't be being paid to make any particular diagnoses at all?

Who's brilliant idea was this? (rhetorical)

edit - wow - it seems my GP may be being paid a lot to have me as a patient.

111 points, at £171.20 each - that may be £19003.20 per year - that's more money than I get in benefits, by quite a lot.

No wonder the NHS costs billions.

edit again- based on my time at the surgery, for everything, and knocking off the cost of drugs, in the last year, that's probably around £10,000 an hour, if I add in time at the hospital, where a NHS person was involved (i.e. not time spent waiting), it's still around £5k p/h - That's probably more expensive per word than lawyers.

So it can't be right, or if it is, it's flaming barmy.

 

[Arnie Pye]

@Wonko Doctors don't get paid multiple times for the same depression diagnosis, as far as I know. It is new diagnoses that get them points, not prescribing for an existing diagnosis. And there is a limit to how many points they can claim for.

But then I also think that GP surgeries have a fixed drugs budget to cover the costs of whatever they prescribe. So, although they may gain by diagnosing certain conditions in a patient for the first time, if they run out of money to cover the cost of the drugs they prescribe they would, presumably, be in serious trouble.

I've always been under the impression that the GP contract and how they are paid and how funding for each surgery is worked out is all a black art, impenetrable to the average patient like me. I think doctors get training in how the system works.

 

[Squeezy]

@Arnie Pye Gob. Smacked.

If this is true, when we come back to the UK in a year and a half, my husband and I will be quite the windfall for whatever GP practice we join.

I guess they're being paid according to how much appointment time depressed patients are reckoned to take up?

I do like that they have to demonstrate appropriate follow up. Maybe that's the point. To motivate over-worked, under-budgeted GP's to keep a close eye on patients with serious conditions.

I've always been under the impression that the GP contract and how they are paid and how funding for each surgery is worked out is all a black art,

Yes, it is! My brother is in General Pediatrics, and has friends who are GP's who work even crazier hours than he does as a hospital doctor. He says the GP system is crumbling. We're losing GP's to emigration, and career change. The stress is enormous. They spend more time on stupid paperwork than patients.

I've got an info graphic about it from him somewhere...

 

[Arnie Pye]

erm..is it just me or does this sound like a recipe for a totally f'd up system. Surely they shouldn't be being paid to make any particular diagnoses at all?

They've done the same in recent years for dementia diagnosis, although I don't think it lasted for very long :

http://www.pulsetoday.co.uk/clinica...-diagnose-and-treat-dementia/20033565.article

With reference to my earlier posts, I should point out that I have no connection with the medical profession and have no training in how the QOF system works, and I may have misinterpreted the rules.

 

[Webdog]

Yea. Before we talk about how to treat it, let's talk about what we mean by it and how we decide if someone's got it (spoiler: all that is a super big mess).
Yes, genuine depression is real - and awful - but the diagnostic category has become way too broad.

In my anecdotal experience as a (misdiagnosed chronic recurring) depression patient, I saw the definition of depression broaden dramatically during the 1990s. It likely wasn't coincidental that a slew of new pharmaceuticals for depression became available around that time.

Many psychiatrists during the 1990s became convinced there was a drug or drug combo for everyone who appeared depressed. I had an unfortunate string of psychiatrists who insisted that brain fog, inability to concentrate, headaches, memory issues, "mild cognitive impairment", fatigue, falling asleep at work, even flu like symptoms and swollen lymph nodes were just "a normal part of depression". Seriously.

Mostly irrelevant personal details:
During the 1990s, when individual antidepressants didn't help, psychiatrists would either try antipsychotics, adding lithium to antidepressants, or mixing drug cocktails of 3-5 medications at a time. Often, these treatments had horrific side effects and/or worsened symptoms. I remember one psychiatrist in particular with a reputation for adding medications until her patients were incapacitated and bedridden.

The aggressive treatment with drug cocktails ended (in my experience) around 15 years ago. Or perhaps that was just my impression because I had no more drugs to try. Those of us who survived through this aggressive treatment era likely all have some liver impairment.

Psychiatry is in denial about this dark 1990's period in their history. Overdiagnosing depression, and wantonly throwing medications at patients convinced that if you try enough of them something is bound to help. And when nothing helps, discarding patients as untreatable, while blaming them for their condition. Two years ago, I discussed my extensive treatment history with a psychiatrist, and she flat out called me a liar and a fraud.

Honestly, its hard not to be scornful of this article. If you're depressed because you're ill, then it seems fairly obvious that the best way to remedy the depression is to address the symptoms of the illness. And that's even assuming they're correct about the depression part to start with.

Agreed.

I know tricyclics are supposed to be good at pain management, but I've never heard of anyone who has actually put this to the test in a placebo-controlled trial.

One of my worst responses to an antidepressant was to a tricyclic (Vivactil). Required hospitalization. The prescription was for fatigue, not pain. My psychiatrist seemed surprised that someone could respond so badly to a simple tricyclic.

The bottom line is that, as a chronically ill person, antidepressants don't help my mood or functioning. At best, they numb me as to how shitty my quality of life is.

It's been 15 years since I've been prescribed an antidepressant. But I'd gladly sign up for any treatment that would help improve functioning and quality of life.

 

[NelliePledge]

Amitriptyline is one of those antidepressants. I know three people who are using it for pain and to help with their sleep.

Yes I had it and now nortryptiline over the last 2 years for sleep - worked ok at first but neither is that effective now. I'm not upping the dose the hangover is too much

 

[Woolie]

I remember one psychiatrist in particular with a reputation for adding medications until her patients were incapacitated and bedridden.

 

[Arnie Pye]

If you're depressed because you're ill, then it seems fairly obvious that the best way to remedy the depression is to address the symptoms of the illness.

I agree. But I've had doctors telling me most sincerely and with a very earnest expression on their faces that if I'm depressed because I'm ill then taking anti-depressants will fix the underlying illness as well as the depression. The utterly bizarre back-to-front logic behind that would be clear to the average 5-year-old. However, doctors have made it clear to me on a few occasions that I will get no other treatment - it's the anti-depressants or nothing. In the early days I did accept anti-depressants a few times but they never helped, and in a couple of cases they actively harmed due to side effects. I've tried 4 different SSRIs in my life. I will never try any more and I walk away if they get offered.

I resent the fact and am angry about the fact that doctors glibly push addictive drugs on to me, and never mention the addictiveness or the possibility of severe and possibly disabling withdrawal symptoms.

 

[Woolie]

But I've had doctors telling me most sincerely and with a very earnest expression on their faces that if I'm depressed because I'm ill then taking anti-depressants will fix the underlying illness as well as the depression.

Yes, I suspect that the vast majority of primary care doctors believe ME is psychological. They make these apparently illogical statements in order to conceal their real beliefs - that you are continuing to make yourself ill through your thoughts, feelings and behaviours.

If they are caring and good diplomats, you won't ever know what they really think. I did wonder why my - apparently kind - doc was so discouraging about referring me to a rheumy (privately, at my own expense). But when I did get an alternative diagnosis via this route his entire attitude changed overnight.

Everyone should assume their doctor is just humoring them unless they have powerful evidence to the contrary.

 

[Inara]

What is in it for UK doctors you ask? £1712 per new diagnosis of depression.

There was a head of a big statutory health insurance company who said that doctors make look patients sicker than they are on paper so that the insurance can charge more. The insurance even calls and speaks with doctors about this and offer a fixed sum per case if the doctors agree to do this.

 

[Inara]

I had an unfortunate string of psychiatrists who insisted that brain fog, inability to concentrate, headaches, memory issues, "mild cognitive impairment", fatigue, falling asleep at work, even flu like symptoms and swollen lymph nodes were just "a normal part of depression". Seriously.

I was told that there exists depression that manifests in the body alone, i.e. without any "psychological" symptoms. That's broadening, I'd say. Mix that with "somatoform disorders" and everything can be explained. Actually, how would "body depression" be differentiated from "somatoform disorders", I wonder?

 

[Inara]

But I've had doctors telling me most sincerely and with a very earnest expression on their faces that if I'm depressed because I'm ill then taking anti-depressants will fix the underlying illness as well as the depression.

There's always something new to learn, quite incredible this

I resent the fact and am angry about the fact that doctors glibly push addictive drugs on to me, and never mention the addictiveness or the possibility of severe and possibly disabling withdrawal symptoms.

That's what makes me angry, too.

 

[Wonko]

That's what makes me angry, too.

Wow!!!

It must be nice to only be angry about one thing

 

[NelliePledge]

I take low dose antidepressant for sleep.

I think it also depends on dosage. The dose I take for sleep is so small, not even close to the dosage recommended for depression.

Apparently some anti-depressants work well for menopause too.

Dunno about working well either for sleep or menopause. I think often people keep taking them cos they make a bit of a difference. Im working on getting something to replace Nortryptiline for sleep as the benefit is barely worth the negatives.
Not heard of them being used for Menopause I was a long term user of Prozac when I hit Menopause and it didn't prevent my symptoms - same goes for ME which is why I think ADs for ME is dubious

 

[Mij]

@NelliePledge I never took anti-depressants for menopause, but my GP suggested it and said it worked well. I don't know which one she would recommend but I decided not to go that route. I'm thinking it's used to take the 'edge' off menopausal symptoms and not much else?

Trazodone is an anti-depressant that gives me deep restorative sleep. It's worked very well for me for the last 16 years.

 

[MErmaid]

What is depression supposed to be anyway, it mostly seems like a label applied to all sorts of problems that share a reduction in vitality as common symptom.

Exactly. I don’t think there is a common ageeement, among all the professionals, as to what depression really is. Many drug studies are so vague, that I often wonder if people, who report an improvement with antidepressants are just experiencing a placebo effect. All of the people I know that take psych meds for depression are still depressed, even though some think they have improved.

In the US, antidepressants are huge money makers for Big Pharma. So I feel they are more about profit than anything else. MDs here hand them out like candy.

 

[Woolie]

I was told that there exists depression that manifests in the body alone, i.e. without any "psychological" symptoms. That's broadening, I'd say. Mix that with "somatoform disorders" and everything can be explained. Actually, how would "body depression" be differentiated from "somatoform disorders", I wonder?

That's seriously messed up.

Not to mention lazy thinking.

 

[Mij]

Dunno about working well either for sleep or menopause.

I forgot to mention, trazodone doesn't work that well for 'menopausal insomnia', night sweats etc. On occasion it doesn't even put me to sleep. I should probably up the dose but don't want to because it has caused dizziness in the past.

Trazodone works well for M.E related insomnia. Interesting.